CT 31.

01 CAP PLAN OF CARE

Community as Partner (CAP) Plan of Care Report for Census Tract (CT) 31.01
Morgan Frank, Jennifer Garred, and Rachel Lima
University of Arizona College of Nursing

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Introduction

This Community as Partner plan of care is based on census tract (CT) 31.01 in Pima
County (PC), which is located in Tucson, Arizona. The community data was gathered through
windshield surveys and key informant interviews. This information then allowed for the
development of several priorities of care and the implementation of an evidenced-based
education project addressing one of those priority needs to members of the community.
Community Nursing Assessment
Core
In accordance with the PC Health Department Public Health Department Nursing
Community Profile CT 31.01, [PCHD CT3101] (2016), the following information depicts the
community core. Each of the following statistical comparisons between the CT and PC reflect
the data that comprises the majority of both populations. Regarding race, 82.3% of the CT
population is white compared to 81.7% in PC. In terms of ethnicity, 32% of the population
within the CT considered themselves to be Hispanic or Latino as opposed to 35.4% in PC. Most
people within the CT fall within the 20 to 44 age range, specifically 47.9%, compared to 32.6%
in PC. In terms of the primary language spoken at home, the CT and PC have more English only
speakers, specifically 76.1% and 71.4% respectively. In conjunction with the aforementioned
numeric data, we observed numerous ethnic restaurants during our windshield survey of the CT.
There were also people within the community dressed in cultural attire (PCHD CT3101, 2016).
Subsystems
Physical environment. The boundaries of the CT include East Pima Street, East 1st
Street, North Swan Road, and North Richey Boulevard. Regarding the age of the homes, most
houses (34%) in the CT underwent construction between 1960-1979. On the other hand, most of

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the homes in PC (35.4%) were built from 1980 to 1999. In terms of housing types, the CT
contains mostly multiplex homes (48.8%), while most of the houses in PC are single family
homes (66.7%). During the windshield survey, only a few of the houses observed appeared well
maintained. However, there was a new sidewalk undergoing construction on East Pima Street,
which was perceived as a positive addition to the CT (PCHD CT3101, 2016).
Education. Most CT residents (84.6%) are high school graduates or higher, which is
similar to PC at 87.5%. Regarding educational community resources, the CT is part of the
Tucson Unified School District (TUSD), and both Basis-Middle Charter School and Desert
Springs Academy Charter School are located within the CT (PCHD CT3101, 2016).
Safety and transportation. Within this CT, there is no police, sheriff, or fire
department. However, Tucson Police Department and Tucson Fire Department serve this CT.
Within the last six months, there have been a total of 96 violent incidents, 166 property incidents,
and 132 quality of life incidents. Also, there are 7 registered sex offenders that live within this
CT. Regarding transportation, multiple bus stops and bike paths are located within the CT. The
predominant hazard regarding street conditions is the presence of large trash items overflowing
into roads outside of three homes, potentially blocking the roadway (PCHD CT3101, 2016).
Politics and government. This particular CT is within the Tucson city limits. It is part of
city ward 6, Pima County district 5, state legislative district 9, and US congressional district 2.
During the windshield survey, political campaign posters were present on nearly every corner of
every intersection, including within the residential areas (PCHD CT3101, 2016).
Health and social services. The two nearest hospitals to this CT are Banner University
Medical Center Tucson and Tucson Medical Center. There is also a long-term care center,
namely Grooves Assisted Living, and the Heart Center of Southern Arizona. Bhat Internal

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Medicine is the only location in the CT that houses two primary care physicians. In addition,
there is a CVS Pharmacy with a MinuteClinic, two eye treatment facilities, and a dental facility.
For those people who may prefer complementary and/or integrative care, the Swan Clinic of
Natural Healing is an option. Regarding social service agencies, present in this CT is the
Arizona Department of Veterans Services and Youth on Their Own (PCHD CT3101, 2016).
Communication. The Martha Cooper Library is the only site with free internet access,
excluding WIFI sources, in the entire CT (PCHD CT3101, 2016).
Economics. A windshield survey of the CT revealed the presence of: check cashing
centers, a convenience store, fast food restaurants, gas stations, a laundry/dry cleaner, a
neighborhood market, a post office/UPS store, a supermarket, and a thrift/resale shop. The
percent of people within the CT that have no health insurance coverage is 27.2% compared to
14.5% for PC. The median household income for this CT is $25,319 whereas that number is
$46,233 for PC. Finally, the percent of all people living in poverty in this CT is 38.6% whereas
in PC it is 19% (PCHD CT3101, 2016).
Recreation. The primary recreational resource for this CT is the Martha Cooper Library,
which offers a game lounge, recess time for children, crochet night, and English as a Second
Language classes for adults (Martha Cooper Librarian, personal communication, October 13,
2016). There is one school yard at Basis Elementary School. This CT also contains a bowling
alley, adult entertainment club, and an adult toy and book store (PCHD CT3101, 2016).
Community Nursing Diagnosis
Strengths
Despite the underprivileged population in CT 31.01, there are many notable community
strengths. The three most pertinent strengths include adequate, reliable public transportation,

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access to schools with programs and accommodations for refugee children and those from lowincome families, and a strong sense of community. These community strengths were noted by
the Pima County Health Department (PCHD) registered nurse (RN) and the librarian from
Martha Cooper Libraryboth key informant interviewees.
The PCHD RN stated that good public transportation is a strength of this community, as
there are multiple bus stops throughout CT 31.01 (personal communication, October 13, 2016).
After visiting the Sun Tran website and viewing the system-wide map, we learned that there are
seven different bus routes that run through the CT, which are primarily along Pima Street,
Speedway Boulevard, Alvernon Way, and North Swan Road (Sun Tran, 2016).
The PCHD RN also shared with us that CT 31.01 is in close proximity to Catalina High
School (CHS), which has special programs for refugee children, as well as Wright Elementary
School, where there is a Head Start program for preschoolers (personal communication, October
13, 2016). The World Refugee celebration was held at CHS on June 18th of this year,
demonstrating the schools support of refugee children and families (TUSD, 2016). Head Start is
a federally funded program that prepares young children, ages five years and younger, from lowincome families for school by comprehensively promoting their development and encouraging
parent involvement (Child-Parent Centers, 2013). Wright Elementary School was verified as a
Head Start location via the Child-Parent Centers website (Child-Parent Centers, 2013).
The librarian at Martha Cooper Library stated that there is a strong sense of community
within the CT, which she witnesses day-to-day as community members come together at the
library for various programs and services (personal communication, October 13, 2016).

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Stressors
There are many stressors that community members residing in CT 31.01 face. The three
most prominent stressors are: inadequate mental health services, lack of knowledge regarding
dental care, and low health literacy specific to medication usage and compliance (see Appendix
for the Priorities of Care Table). These stressors were identified by key informant interviewees,
including a psychologist, PCHD RN, CVS pharmacist, physician from CVS MinuteClinic, RN
from Casa de los Nios, and the librarian at Martha Cooper Library.
Inadequate mental health services was identified as a primary concern for this community
by each of the aforementioned key informants. Each stated that there is a large number of
residents with mental health problems in CT 31.01 and that mental health care facilities and/or
access to services are scarce (Psychologist, PCHD RN, CVS Pharmacist, CVS MinuteClinic
Physician, Casa de los Nios RN, & Martha Cooper Librarian, personal communication, October
13, 2016). Inadequate dental care was explicitly identified by the Casa de los Nios RN and the
PCHD RN. They stated that there is a need for affordable dental care as well as education
regarding its importance, especially in children (Casa de los Nios RN & PCHD RN, personal
communication, October 13, 2016). The third community stressor, low health literacy specific to
medication usage and compliance, was mentioned by both the psychologist and the CVS
pharmacist. These key informants stated that residents have difficulty understanding medication
regimens largely due to generally poor health literacy (Psychologist & CVS Pharmacist, personal
communication, October 13, 2016).
Community Nursing Diagnosis
The priority concern for CT 31.01 that will be addressed in depth throughout the rest of
this paper is the apparent knowledge deficit amongst community members regarding the

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importance of dental care. We developed a nursing diagnosis for this community stressor in
order to determine an appropriate plan for addressing this concern. The community nursing
diagnosis is as follows: Risk for development of dental caries among residents of CT 31.01,
specifically the pediatric population, related to knowledge deficits and misperceptions regarding
the importance of dental care and how nutrition impacts oral health, as evidenced by key
informant interviews in which several interviewees noted lack of knowledge regarding dental
care as being a primary concern for this CT.
Community Nursing Plan
Good Goal
The goal of this program is to increase awareness in school age children residing in or
near CT 31.01 regarding how their food choices affect the health of their teeth.
Intervention
On November 1, 2016, we will give a short, simple presentation to as many school-aged
children as are present at the Martha Cooper Library, using a poster board designed to
communicate basic information regarding dental nutrition to this age group. We will then engage
the participants in an interactive activity to exercise their new knowledge, and provide each with
a toothbrush in a color of his or her choice as a reward for participation. We will remain present
to perform this intervention for the duration of one hour.
Evidence-Based Article
The evidence-based practice (EBP) article used to support this intervention is entitled,
The influence of oral health conditions, socioeconomic status, and home environment factors on
childrens self-perception of quality of life, (Paula et al., 2012). This study used a qualitative
questionnaire of 515 school-aged children to investigate the influence of clinical conditions,

CT 31.01 CAP PLAN OF CARE

socioeconomic status, home environment, and subjective perceptions of parents and school
children about general and oral health on school childrens oral health-related quality of life
(OHRQoL) (Paula et al., 2012). The results indicate that low socioeconomic status, amongst
other factors, was significantly associated with poor OHRQoL (P < 0.001). Because the CT
31.01 population is generally of low socioeconomic status, this study suggests that the potential
for the presence of poor OHRQoL in this population is high. When combined with the apparent
disparity in access to dental health care, this study supports the need for an intervention to
improve dental health, which would then consequently improve perceived OHRQoL.
Healthy People 2020
The Healthy People 2020 (HP2020) Overarching Goal that is most applicable to our
community education project is the goal to promote quality of life, healthy development, and
healthy behaviors across all life stages (Office of Disease Prevention and Health Promotion
[ODPHP], 2016, About Healthy People-Overarching Goals, para. 1). The most relevant HP2020
topic area is Oral Health, with the goal to prevent and control oral and craniofacial diseases,
conditions, and injuries, and improve access to preventive services and dental care (ODPHP,
2016, Oral Health-Overview, para. 1). Within the topic area of Oral Health, the subtopic entitled
Oral Health of Children and Adolescents is more specific to our community education project, as
the target population was school-aged children. Objective number OH-1, found under Oral
Health of Children and Adolescents, is the most pertinent to our project, with the objective to
reduce the proportion of children and adolescents who have dental caries in their primary or
permanent teeth (ODPHP, 2016, Oral Health-Objectives, para. 1).

CT 31.01 CAP PLAN OF CARE

Policy/Legislation
The American Nurses Association (ANA) Standards of Public Health Nursing Practice is
a current policy related to our health education project (ANA, 2013). Standard 5B of this policy
lists Health Teaching and Health Promotion as a standard of practice for a public health nurse.
We complied with this standard by engaging the community in our health education project in an
effort to promote dental health.
Program Plan
By 10/28/2016, the student nurses will confirm the date and time of their health education
project with Martha Cooper Library. By 10/31/2016, all education presentation items will have
been reviewed and approved by the college of nursing faculty, Pima County Health Department
Nurse, and Martha Cooper Library representative. By 11/01/2016, we will have completed the
education presentation to participating children at the Martha Cooper Library (see Appendix B
for photo of visual aid).
Collaboration with Community Partners
To implement our intervention, we collaborated with the Martha Cooper librarian to
establish the best location and time to schedule the presentation based on when the most
participants would be present in the library. Collaboration with the librarian also enabled us to
identify the primary concerns of the population, so that we could plan our intervention. Our
communication back-and-forth was prompt and clear, and we came across no obstacles to
accomplishing our collaborative goals. In addition, we worked closely with the PCHD RN
assigned to this CT to ensure that her feedback was accounted for in the presentation and that she
was informed of our whereabouts and interventions. A challenge of working with the PCHD RN

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was that she had recently moved to this area from out-of-state, so she was learning alongside us
and was not able to provide us with as much insight as we had anticipated.
Levels of Prevention
Our community health education project addresses all three levels of prevention. Our
target population of school aged children includes children who have completely healthy teeth,
those who are unaware that they have dental caries, and those who have known dental caries. In
children who have healthy teeth, the health problem is being addressed in the susceptibility stage
of the natural history of disease, making the intervention primary prevention (McFarlane &
Gilroy, 2015). The goal for these children is to target the health problem before it exists. In
children who have dental caries but are unaware of their presence, the health problem is being
addressed in the early subclinical stage, making the intervention secondary prevention
(McFarlane & Gilroy, 2015). The goal for these children is to identify the problem soon enough
to cure it or prevent disability. In children who already have confirmed dental caries, the health
problem is being addressed in the stage of clinical disease, making this tertiary prevention
(McFarlane & Gilroy, 2015). The goal for these children is to target an established health
problem to prevent progression of the problem.
SMART Objectives
The first objective is that by the end of the teaching session, 95% of the children sampled
will be able to accurately identify four food items that are beneficial to oral health and four food
items that are harmful to oral health. The second objective is that by the end of the teaching
session, 100% of participants will be able to state one food item they eat at home that is harmful
to their teeth, and one food item that is good for their teeth that they can eat instead.

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Resources and Constraints

Required resources for the health education project included art supplies to create the
poster, time to create the poster and present it to the participants, toothbrushes to provide as
rewards, and a physical location to provide the education. Each of the resources that we needed
were available to us, so we did not encounter any constraints.
Implementation of Community Nursing Intervention
Process Evaluation
Various observations were made during the presentation of our health education project.
We noticed that community members initially approached us cautiously, appearing curious
regarding why we were there but unsure of whether or not they wanted to participate. However,
as we began talking to them and explaining our education project, their demeanors changed from
cautious to engaged. The participants seemed receptive to the material we were presenting.
Twelve children and one adult participated in our education project. The biggest
challenge we faced was adjusting the content complexity for the youngest participants
(approximately four years of age). Another challenge was that participants would often approach
the booth in the middle of a presentation to another child, and would hear some of the answers
before participating in the activity. This posed a challenge to accurate evaluation of the
effectiveness of our teaching.
Evaluation of Community Nursing Intervention
Impact Evaluation
The first SMART outcome was evaluated by Jen and Rachel during the interactive
activity to assess the effectiveness of the initial teaching session. After providing the participants
with general information regarding dental nutrition, they were encouraged to play a game in

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which they must identifybased on the information providedfour food items on the poster
that are good for dental health, and four that are bad. We then discussed with each participant
why each food item was either good or bad to fill any gaps in information provided and clarify
any misconceptions. Then, Morgan evaluated the second SMART outcome by asking each
participant to identify one food item (not seen on the poster board) that he/she eats at home that
is bad for their teeth, and one food item that is good for their teeth and can be eaten instead. A
tally was taken of the number of participants who could answer both, only one, and neither of the
questions correctly (see Appendix C for evaluation tool). To disseminate the results of this
evaluation, we presented our findings to a panel of PCHD nurses who serve this population.
Evaluation of the first outcome revealed that for nearly every participant, the initial
teaching session alone was not enough to help the children learn, understand, and apply the
content. Only two of the twelve participants (16.7%) were able to accurately distinguish the four
healthy food items from the four unhealthy ones on their first attempt, but neither could justify
their selections with new knowledge. For example, they were able to identify the soda bottle as
an unhealthy food item, but only because they know soda is bad. All other participants needed
extensive guidance to distinguish between the healthy and unhealthy food items on the board.
Evaluation of the second outcome revealed similar results. Even after engaging in the interactive
activity, the majority of participants struggled with applying new knowledge to answer
evaluation questions. Six participants (50%) were able to accurately identify both an unhealthy
and healthy food item, but most needed suggestive hints to guide them in the right direction.
One participant was only able to identify a healthy food item (8.3%), and one participant was
only able to identify an unhealthy food item (8.3%). Four participants (33.3%) were unable to

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identify either food item; these were generally the youngest, and thus at the lowest level of
cognitive development.
Conclusion
The number of participants available to engage in this intervention far exceeded our
expectations. Perhaps more surprising was the observation that regardless of the participants
age or cognitive level, each one seemed to struggle with applying the new information to what
we originally thought to be a simple question. Moving forward, this intervention can be
improved by narrowing the targeted age-range that the teaching session is designed to target, as
effective teaching methods vary widely based on age. In addition, perhaps the method via which
the information is initially presented should be adjusted. Instead of simply stating the facts to the
children, we could draw their attention and concentration through the use of visual aids to
illustrate the information or by telling a story that illustrates the key concepts. Overall, we are
satisfied with outcomes of the program and confident that it made a difference in the dental
health of at least one individual in need

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Appendix A
Priorities of Care Table

Inadequate
mental health
services

Low health
literacy,
specific to
medication
usage and
compliance
Lack of
knowledge
about benefits/
importance of
preventative
healthcare

Lack of

Identified in
Pima
Countys
Health
Needs
Assessment

Community
expression
of interest in
addressing
problem

Nursing
students
ability to
address
problem

Availability
of resources
relevant for
addressing
problem

Severity of
outcome(s)
without
effort to
address
problem

Applicable
HP2020
Determinant
of Health
category

Health
Services

Individual
Behavior

Individual
Behavior

Individual

Nursing Intervention
(From Minnesota Wheel)

Advocacy: Write a letter to a legislative

representative requesting their support in
establishing a mental health facility in the
31.01 census tract.

Collaboration: Encourage pharmacists to give

print materials with clients medications that
are written at a 3rd grade reading level (CDC
recommended reading level that is
comprehensible by the general public)

Outreach: Create an event that would bring

together primary health care providers who
could advertise/promote their services and
educate about the importance of
preventative health care

Health Teaching: Teach a class at the library

Total score

Community
health concern
or problem,
(stressor, risk
factor, need,
determinant)

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knowledge
regarding
dental care
Limited
knowledge
regarding
nutritional
value of whole
vs. processed
foods

15
Behavior

Individual
Behavior

addressing the communitys lack of

knowledge regarding dental care

Health Teaching: Teach a class at the library

addressing the nutritional value of whole vs.
processed foods

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Appendix B

Visual Aid for Community Education Project

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Appendix C
Evaluation Tool

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References

American Nurses Association. (2013). Public health nursing: Scope & standards of practice (2nd
ed.). Silver Spring, MD: Nursebooks.org.
Cavity Free Kids. (n.d.). Basics of oral health 3: Tooth healthy foods. Retrieved from
http://cavityfreekids.org/activities/basics-of-oral-health-3-tooth-healthy-foods/
Child-Parent Centers. (2013). Child-parent centers locations. Retrieved from
http://www.childparentcenters.org
Child-Parent Centers. (2013). Head start FAQs--What is head start. Retrieved from
http://www.childparentcenters.org/questionheadstart?catid=0
McFarlane, J., & Gilroy, H. (2015). Epidemiology, demography, and community health. In
Anderson, E. T. & McFarlane, J. (Eds.), Community as partner: Theory and practice in
nursing (7th ed.). Philadelphia: Wolters Kluwer.
Paula, J. S., Leite, I. C., Almeida, A. B., Ambrosano, G. M., Pereira, A. C., & Mialhe, F. L.
(2012). The influence of oral health conditions, socioeconomic status and home
environment factors on schoolchildren's self-perception of quality of life. Health and
quality of life outcomes, 10:6. doi: 10.1186/1477-7525-10-6
Sun Tran. (2016). System-wide map. Retrieved from http://www.suntran.com/PDF/Maps/Shelter
%20Map%20-%20Aug%2016.pdf
U.S. Department of Health and Human Services, Office of Disease Prevention and Health
Promotion. (2016). About healthy people. In Healthy People 2020. Retrieved from
https://www.healthypeople.gov/2020/About-Healthy-People

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U.S. Department of Health and Human Services, Office of Disease Prevention and Health
Promotion. (2016). Oral health-Objectives. In Healthy People 2020. Retrieved from
https://www.healthypeople.gov/2020/topics-objectives/topic/oral-health/objectives
U.S. Department of Health and Human Services, Office of Disease Prevention and Health
Promotion. (2016). Oral health-Overview. In Healthy People 2020. Retrieved from
https://www.healthypeople.gov/2020/topics-objectives/topic/oral-health
U.S. Department of Health and Human Services, Office of Disease Prevention and Health
Promotion. (2016). 2020 topics and objectives-Objectives A-Z. In Healthy People 2020.
Retrieved from https://www.healthypeople.gov/2020/topics-objectives